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Professionalism in Medicine
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  • 3 b/w illus. 3 tables
  • Page extent: 482 pages
  • Size: 253 x 215 mm
  • Weight: 0.82 kg
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 (ISBN-13: 9780521704922)

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Professionalism in Medicine
Cambridge University Press
9780521879323 - Professionalism in Medicine - A Case-Based Guide for Medical Students - Edited by John Spandorfer, M.D., Charles A. Pohl, M.D., Susan L. Rattner, M.D., M.S. and Thomas J. Nasca, M.D.
Excerpt

Introduction

Concerns have been raised, both within and outside medicine, that physicians and the medical education system have lost their commitment to medical professionalism. One senses that in the perennial struggle between self-interest and altruism self-interest may be winning out. The realities of today’s medicine, including commercialism, conflicts of interest, decreased autonomy, and increased oversight, have led to the erosion of the idealistic values expected of physicians since the conception of the Hippocratic Oath. This attrition of professionalism has, in turn, led to renewed calls to refine how professionalism is taught in medical schools. Many organizations, including the Association of American Medical College, the Accreditation Council for Graduate Medical Education, and the American College of Physicians have advocated initiatives to emphasize professionalism in medicine and medical education.

Despite the calls for change, challenges remain about how an ethos of professionalism should be inculcated in doctors-in-training. Professionalism is taught in the explicit and the implicit curriculum in most medical schools. Early in their education, students are first taught professionalism through the explicit curriculum. This occurs mainly during lectures, small group discussion and isolated events, including the “white coat ceremony.” The challenge with learning professionalism in these settings is manifold. The explicit curriculum (1) may not be consistently and readily integrated with the four-year curriculum; (2) may be overly simplistic; (3) tends to focus more on the negative aspects of professionalism (such as using lists of rules and behaviors and describing the negative consequences of bad actions); and (4) lacks a single resource or text used for teaching students about medical professionalism. Perhaps the greatest challenge of learning professionalism is that the behavior stressed in the classroom setting is only partially corroborated by the students’ experience in the clinical setting. As students advance in their training, learning professionalism skills increasingly occurs through the implicit, or hidden, curriculum. Values that were learned in lecture, small groups, and ceremonies become less memorable as students are more influenced by what they observe first-hand. Unfortunately, many of these first-hand observations are not ideal. Students often complain that a significant number of their educators display unprofessional conduct. The adage “do as I say, not what I do” well describes the conflict students have as they consider both their lessons learned in the classroom and in real-world settings. The cognitive dissonance generated through exposure to unprofessional behaviors in the hospital and outpatient setting frustrates and confuses students, and the behaviors observed trump those of the explicit curriculum every time!

Another challenge to teaching about this subject is gaining a common understanding of what the term professionalism means. Many physicians claim to “know it when they see it,” yet when pressed have difficulty defining it. Each profession – the clergy, law, engineering, architecture, and the multiple professions of medicine – has at its foundation a social contract between that profession and society. From this perspective, professionalism may be defined as the means by which members of that group fulfill the obligations of that profession’s social contract. In the case of medicine, several benefits may follow from the contract. One benefit is that the profession is permitted to autonomously set expectations and guidelines for the field, while it regulates and disciplines physicians when deviation from standard practices occur. The returned benefit for society from the social contract is that it can then trust that physicians will be capable, moral, accountable, and will act in the best interest of those whom they are serving.

Our primary goal in the creation of Professionalism in Medicine: A Case-Based Guide for Medical Students is to give medical educators and medical students a resource that can be useful throughout the four years of the medical school experience. We aim to facilitate discussion and further understanding of a wide range of topics within the domain of medical professionalism. Following a review in Part I on how professionalism has been defined, the book is organized around a collection of cases, commentaries, and literature reviews. The seventy-two cases portray real life medical challenges that are relevant to the experiences of medical students. Many of the cases focus on ethical dilemmas where there is no clear resolution. Some are dilemmas encountered where solutions may be easier, but other issues arise that demand deliberation. And still other cases broach topics where students and physicians struggle with the friction between the patient’s welfare and the practitioner’s own self-interest. Through applying clinical judgment and fundamental ethical and professionalism principles, the commentators explore reasoning behind and potential approaches to the case dilemmas.

The organization of this book is based on a view of professionalism described in the publication Medical Professionalism in the New Millennium: A Physician Charter (Ann Intern Med 2002:136:243–246). Developed by the American Board of Internal Medicine, the American College of Physicians, and the European Federation of Internal Medicine, the Charter has been endorsed by specialties throughout the world and in all fields of medicine. The Charter recognizes a set of three principles and ten professional responsibilities that must be practiced by the medical profession and understood by society (see Table). Such an expansive set of ideals, avowed by each physician, allows the public to place their trust in an ideal or virtuous physician.

The Physician Charter

Fundamental Principles

Principle of primacy of patient welfare

Principle of patient autonomy

Principle of social justice

Set of Professional Responsibilities

Commitment to professional competence

Commitment to honesty with patients

Commitment to patient confidentiality

Commitment to maintaining appropriate relations

Commitment to improving quality of care

Commitment to improving access to care

Commitment to a just distribution of finite resources

Commitment to scientific knowledge

Commitment to maintaining trust by managing conflicts of interest

Commitment to professional responsibilities

Very early in their medical education – with the start of anatomy dissection or with the first patient interview in front of the class – students realize that even this stage in their education presents encounters with ethical meaning. In Part II of the book, medical students are the central characters in cases. Each of the thirteen areas of the Physician Charter is explored by two cases, one in which the student is at an earlier stage in his or her medical education, and one later. Following each case, two commentaries are written, one authored by a faculty member and another by a medical student. Many of the cases raise issues asking students to balance their own health and welfare, their own expectations, or their own educational needs with the needs of their patients and with their vulnerable status in the academic educational hierarchy.

Students aspire to learn from situations in which doctors have the leading role. The cases in Part III, the main section of this text, shift to vignettes based on situations that physicians across medical specialties encounter. This section comprises forty-two cases, each followed by two commentaries that explore eight of the thirteen areas of professionalism in the Physician Charter: the three principles (patient welfare, patient autonomy, and social justice) and five of the professional responsibilities (honesty with patients, patient confidentiality, improving quality of care, managing conflicts of interest, and professional responsibilities). Following each case, two commentaries are authored. The first, a physician commentary, is written by specialists from family medicine, internal medicine, obstetrics-gynecology, pediatrics, psychiatry, surgery, neurology, and emergency medicine. The physician-commentator briefly describes the clinical issues that are relevant to render a judgment, explains the salient professional issues to be considered, and offers an opinion about how they would proceed with resolving the dilemma.

A second commentary is included because it is important to understand that perspectives and approaches to the cases will differ. The authors of these commentaries represent a wide variety of voices, each with a stake in health care decisions. These authors include ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health administrators, health service researchers, patient advocates, and other medical educators. Family members of patients also comment on several of the cases. A unique format for learning about medical professionalism has been created with the video production of eight of the cases. These cases are brought to life by specially trained standardized patients from the Rector Clinical Skills and Simulation Center at Jefferson Medical College of Thomas Jefferson University. For access to the videos and more information on medical professionalism, see http://professionalism.jefferson.edu/.

Professionalism requires not only allegiance to the qualities discussed in the Physician Charter, but also an understanding of the medical literature and an awareness of where opinions originate. With this in mind, each of the eight areas of medical professionalism in Part III includes a comprehensive literature-based review of that topic. The authors also reflect on the commentaries and connect these writings with current literature.

Learning medical professionalism is a challenging, evolving, lifelong endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students will help this process by engaging students and their teachers in reflection on and discussion of cases that will resonate with life experiences. If this text, reinforced by appropriate clinical role models, fortifies the aspirations of future physicians to practice medicine guided by the precepts of professionalism, we will have achieved our purpose.




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